When a resident is unable to stand the residents height is generally obtained by?

Height and weight are documented upon admission to a facility as a baseline measurement and then taken routinely. Accurate weights are required for calculating medication dosages, ensuring adequate food and fluid intake, and monitoring chronic conditions such as heart failure (because weight gain is often the first indication of an impending problem).

If a resident requires as documented in their care plan, their weight should be taken on the same scale at the same time every day, before any food or fluids are consumed, and while wearing a similar amount of clothing. The weight is documented, and weight changes of 3 pounds over 24 hours or 5 pounds within a week should be immediately reported to the nurse to address any possible complications. See the “Measuring Weight for Ambulatory Residents” Skills Checklist for measuring weight for more details.

If a resident is nonambulatory, the nursing assistant should weigh the wheelchair and any associated accessories (such as foot pedals or a chair cushion). After the resident is dressed and groomed, the nursing assistant should bring them to the scale, obtain the weight, and then subtract the weight of the chair and associated accessories. See Figure 7.13[1] for an image of weighing a resident on a wheelchair scale.

If a resident requires transfer with a full-body mechanical lift, some lifts have a scale function that can weigh the resident as they transfer from bed to wheelchair.

Height

Resident height is typically obtained on admission and documented in the medical record. Because height rarely changes, measurement is rarely repeated. See the “Measuring Height for Ambulatory Residents” Skills Checklist for measuring the height of an ambulatory person with a stadiometer. Figure 7.14[2] shows a person being measured with a stadiometer. If a resident is nonambulatory or unable to stand, their height can be measured with a tape measure while they are lying in bed. Height is recorded in inches or millimeters based on agency policy.

Body Mass Index

Nursing assistants may be asked to obtain a height and weight to calculate a resident’s Body Mass Index (BMI). is a calculated measure of body fat based on a person’s height and weight. It is calculated by dividing weight in kilograms by the square of their height in meters. BMI is used to evaluate if an individual is underweight (BMI less than 18.5), normal (BMI 18.6-24.9), overweight (BMI over 25), or obese (BMI over 30). Elevated BMI measurements are associated with cardiovascular disease, type 2 diabetes, and other chronic diseases.[3]

Before helping a resident to stand who has been lying in bed, the nurse aide needs to

allow time for the resident to adjust to sitting at the edge of the bed.

The nurse aide can help the resident have regular bowel movements by

providing a routine time for the resident to toilet.

Why should residents who are unable to change their own positions, have their positions changed by staff at least every two hours?

Promote circulation at pressure points

A resident wears a hand splint. Which observation should the nurse aide report to the nurse immediately?

The resident's fingers are cold and blue in color.

While helping in the dining room, the nurse aide notices a male resident in distress holding his throat. The nurse aide believes the resident may be choking. After calling for help, the nurse aide's next action should be to

ask if the resident can talk.

Which of the following is an example of disinfection?

Cleaning a shower chair with a chemical cleanser

A resident reports having a very large bowel movement two days ago. What should the nurse aide do first?

Ask if this is a normal pattern for the resident's body.

A few minutes before the end of the shift, a resident calls and whispers to the nurse aide, "I had an accident. I wet myself." What should the nurse aide do?

Provide incontinent care to the resident.

When feeding a resident who is lying in bed, the head of the bed is raised to

decrease the risk of aspiration.

A charge nurse asks a nurse aide to perform a task that is not part of the nurse aide's scope of practice. What should the nurse aide do?

Refuse to perform the task and explain it is not within the nurse aide's role.

A resident who is wearing a hearing aid keeps asking the nurse aide to repeat information. Which of the following actions should the nurse aide do first?

Make sure the hearing aid is turned on.

A resident is restrained. What observation should the nurse aide report to the nurse immediately?

The restraint was removed according to the care plan schedule.

When a resident is unable to stand, the resident's height is generally obtained by

taking the measurement from head to heels while the resident is flat in bed.

A resident is being showered while sitting in a showerchair. The resident says, ""I feel weak. I think I am going to faint." The nurse aide's immediate concerns are calling for help and

keeping the resident safe and comfortable.

A resident, who is usually alert and oriented, is having difficulty remembering where he is today. What should the nurse aide do first?

Report the change to the charge nurse.

A resident tells the nurse aide that she has pain down her arms and into the jaw and that she feels nauseated. The nurse aide observes that the resident appears pale and is sweating. The nurse aide should

recognize the seriousness of the signs and observations and report immediately.

Symptoms of a heart attack include pain radiating to arms and jaw and diaphoresis (sweating). it should be reported to the nurse.

A resident's hands shake when trying to drink liquids, causing the liquids to spill. What is the best response by the nurse aide?

Suggest that the resident might do well with a cup with a lid.

The nurse aide is taking routine vital signs on a resident. The resident's temperature is 101.4º Fahrenheit. The most appropriate response by the nurse aide is to

report the temperature promptly.

To help prevent residents who are confused from accidentally leaving the nursing home, the nursing home may

place large stop signs on doors.

A resident with an indwelling catheter says, "I need to urinate." Which of the following is the best response by the nurse aide?

Check to see if the tubing is kinked and draining properly.

"Sundowning" is a term used to describe when residents

become restless and agitated late in the day.

Behaviors such as agitation, anxiety, restlessness, and pacing can become more prevalent in the late afternoon and continue into the night for some residents.

When feeding a resident, the nurse aide notices that the resident keeps coughing after each drink of fluids. What is the appropriate response by the nurse aide?

Stop the feeding and report the coughing to the charge nurse right away.

Which of the following is considered a normal age-related change seen in elderly residents?

Decrease in taste sensation and smell.

Which action is most helpful to help decrease a resident's incontinence?

Answering the resident's call light quickly.

A resident's leg has recently been amputated. Since the surgery the resident has not wanted to leave his room. What response by the nurse aide is most supportive?

"You used to enjoy activities. What's keeping you in your room so much?"

A resident with a feeding tube is scheduled for a shower. The resident's feeding tube is connected to a pump. Which of the following is the appropriate response by the nurse aide?

Ask the charge nurse for assistance with the feeding pump.

The care plan requires that the resident be ambulated 100 feet twice a day at 10 a.m. and 2 p.m. When the nurse aide arrives to walk the resident at 10 a.m., the resident refuses. Which of the following is the best response by the nurse aide?

"Would you prefer to walk a little later?"

A resident who is Roman Catholic is dying. The resident comments that she has not been to confession and she worries that she will die in a state of sin. Which of the following is the best response by the nurse aide?

"Would you like it arranged for a priest to visit you?"

Which of the following is the best example of using reality orientation for a resident with early dementia?

"Look at the time. Lunch is in 30 minutes. Are you feeling hungry?"

When a resident has an indwelling urinary catheter, the nurse aide should expect that the resident's care plan will include

keeping the area where the catheter enters the body clean.

A resident with advance directives has a DNR order. This means that the resident

should not be resuscitated.

The goal when removing gloves that are soiled is to

avoid contact with the outside of the gloves.

Which of the following statements is true about how people experience pain?

A person's culture can affect response to pain.

The nurse aide is bathing a resident and notices new swelling in the resident's ankles. Which of the following is the best response by the nurse aide?

Report the swelling to the charge nurse.

A resident falls from her chair when she has a seizure. Before the nurse arrives, the seizure is finished and the nurse aide observes the resident is breathing. What should the nurse aide do next?

Turn the resident onto her side

Which of the following is generally experienced by a resident with low blood sugar?

Weakness.

The symptoms of hypoglycemia are weakness, fatigue, confusion, sweating, and trembling. These symptoms indicate that the resident's blood sugar is too low.

A resident with dementia says, "I need to get home. My daughter's school bus is coming soon." The nurse aide knows the resident is confused because her only daughter just turned 60. What is the best response by the nurse aide?

"What do you like to do with your daughter when she gets home from school?"

The nurse aide is to obtain a resident's weight. The nurse aide should

check what scale is usually used for this resident.

A nurse aide walks into a resident's room and finds a resident on the floor. The resident says, "I fell down and I cannot move my arm." What should be the nurse aide's next action?

Ask the resident to stay still while the nurse aide calls for help.

An alert resident has requested to be left alone with her husband who is visiting. The resident closes the door to her room. What should the nurse aide do?

Allow the resident to be alone with her spouse.

Which of the following describes a resident's concern that needs to be reported to the charge nurse immediately?

A resident who has always been oriented is suddenly scared and confused.

Which of the following is the most appropriate schedule for residents who are incontinent to receive perineal care?

Whenever the resident is soiled with urine or stool.

To help prevent burns to residents during meals, the nurse aide should

let residents know which foods and beverages are hot.

Which of the following is a right of nursing home residents?

To make decisions about their care and treatment.

A nurse aide is assisting a resident at mealtime. The resident grabs his throat and cannot speak. What should the nurse aide do first?

Reach around from behind the resident to provide abdominal thrusts.